Healthcare Provider Details

I. General information

NPI: 1659409365
Provider Name (Legal Business Name): KENNETH WAYNE CAMPBELL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: KENNETH WAYNE CAMPBELL CRNA

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 PELHAM ROAD JACKSONVILLE MEDICAL CENTER
JACKSONVILLE AL
36265
US

IV. Provider business mailing address

727 COUNTY ROAD 8
HEFLIN AL
36264-3651
US

V. Phone/Fax

Practice location:
  • Phone: 256-435-4970
  • Fax:
Mailing address:
  • Phone: 256-253-2885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number26081
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: